Authors

IOM Eyes Big Changes in Graduate Medical Education

Thursday, 31 July 2014

In a New England Journal of Medicinearticle published simultaneously with an Institute of Medicine (IOM) landmark report on the subject, LDI Senior Fellow David Asch writes about the deficiencies of the current $15 billion-a-year Graduate Medical Education (GME) training system.

Currently, the federal government spends $15 billion annually to pay for the residency and fellowship training of young physicians who have just received their medical degrees. The IOM report notes that the scale of financial government support

David Asch, MD, MBA, is an LDI Senior Fellow, Professor of both Medicine at Penn's Perelman School of Medicine and Health Care Management at the Wharton School, and Executive Director of the Penn Medicine Center for Health Care Innovation.

afforded the program "is unlike that given to any other profession."

Competency issuesThe 204-page IOM document is the result of a three-year investigation that found "worrisome evidence that newly trained physicians in some specialties have difficulty performing simple office-based procedures and managing routine conditions. In addition, medical educators report that GME curriculums lack sufficient emphasis on care coordination, team-based care, costs of care, health information technology, cultural competence, and quality improvement -- competencies that are essential to contemporary medical practice. Recent surveys of residents and faculty suggest that they know little about the costs of diagnostic procedures and that residents feel unprepared to provide culturally competent care."

In his NEJM piece, "Innovation in Medical Education," Asch, Executive Director of the Penn Medicine Center for Health Care Innovation, identifies a fundamental problem: the content, logistics and practices of today's GME programs are based on traditions that have aggregated over the last century rather than actual scientific evidence.

Lack of researchAsch, one of the 21-member committee that produced the IOM report, writes in his article, "Our nation's lack of research in medical education contrasts starkly with the large and essential commitment to biomedical research funded by industry, philanthropic organizations, and the public. No one questions the need for sustained support for research in cancer, heart disease, or dementia. But despite medical education's central role in creating a workforce capable of delivering
the resulting biomedical advances... funding for medical education research is conspicuously absent. As a result, we lack evidence that is essential for guiding improvements in the clinical workforce."

The IOM report cites elements obviously in need of transformational improvements: "the current GME program does not produce adequate numbers of physicians prepared to work in needed specialties or geographic areas. Nor does it train physicians to practice in the community-based settings where most Americans seek care. Perhaps most critically, it lacks the oversight and infrastructure to track outcomes, reward performance, and respond nimbly to emerging challenges."

No research budgetAsch writes, "The research that could answer these questions requires funding and organization that don't currently exist. The Centers for Medicare and Medicaid Services pays about $10 billion a year toward GME but has neither a research and development budget to ensure that this investment is achieving its objectives nor even a clear definition of what those objectives are. Overall, the United States spends nearly $3 trillion a year
on health care, nearly all of it delivered through clinicians, with no organized research investment directed at improving the way those clinicians are produced.